Double calibration: an accurate, reliable and easy-to-use method for 3D scapular motion analysis

The most recent non-invasive methods for the recording of scapular motion are based on an acromion marker (AM) set and a single calibration (SC) of the scapula in a resting position. However, this method fails to accurately measure scapular kinematics above 90° of arm elevation, due to soft tissue artifacts of the skin and muscles covering the acromion. The aim of this study was to evaluate the accuracy, and inter-trial and inter-session repeatability of a double calibration method (DC) in comparison with SC. The SC and DC data were measured with an optoelectronic system during arm flexion and abduction at different angles of elevation (0-180°). They were compared with palpation of the scapula using a scapula locator. DC data was not significantly different from palpation for 5/6 axes of rotation tested (Y, X, and Z in abduction and flexion), where as SC showed significant differences for 5/6 axes. The root mean square errors ranged from 2.96° to 4.48° for DC and from 6° to 9.19° for SC. The inter-trial repeatability was good to excellent for SC and DC. The inter-session repeatability was moderate to excellent for SC and moderate to good for DC. Coupling AM and DC is an easy-to-use method, which yields accurate and reliable measurements of scapular kinematics for the complete range of arm motion. It can be applied to the measurement of shoulder motion in many fields (sports, orthopaedics, and rehabilitation), especially when large ranges of arm motion are required.     

Comparison between tripod and skin-fixed recording of scapular motion

Non-invasive dynamical measurements of 3D scapular motion can be performed easily by attachment of a 6 DOF electromagnetic receiver onto the skin above the acromion. To quantify the introduction of possible errors due to skin displacement, we assessed 3D scapular positions on n=8 subjects by both tripod and skin-fixed method. Error analysis included the variables method (tripod, skin-fixed simultaneously with tripod, separate skin-fixed at 0 and 0.25Hz of elevation speed), plane of elevation (0 degrees and 90 degrees ) and observation (receiver replacement: n=3). Inter-individual 'group' differences depended on elevation plane and showed an average underestimation of scapular rotation of 6.5 degrees (worst case 13 degrees ) using the skin-fixed method. Only the group RMSE, not the individual RMSE, could be successfully lowered using linear regression (to about 2 degrees ). Inter-trial reliability (RMSE <3.24 degrees , ICC>0.94) and RMSE between 0 and 0.25Hz recordings (about 2.5 degrees ) were satisfactory. Intra-observer RMSE after replacement of the skin-fixed receiver was 5 degrees . The skin-fixed method is suitable for dynamic recordings of scapular rotations; however, measurements are precise only when the acromion receiver is not replaced. Combined with a relatively low accuracy, we conclude that the skin-fixed method should be used only in combination with tripod 'calibration'.     

Measurement of Dynamic Scapular Kinematics Using an Acromion Marker Cluster to Minimize Skin Movement Artifact

The measurement of dynamic scapular kinematics is complex due to the sliding nature of the scapula beneath the skin surface. The aim of the study was to clearly describe the acromion marker cluster (AMC) method of determining scapular kinematics when using a passive marker motion capture system, with consideration for the sources of error which could affect the validity and reliability of measurements. The AMC method involves placing a cluster of markers over the posterior acromion, and through calibration of anatomical landmarks with respect to the marker cluster it is possible to obtain valid measurements of scapular kinematics. The reliability of the method was examined between two days in a group of 15 healthy individuals (aged 19-38 years, eight males) as they performed arm elevation, to 120°, and lowering in the frontal, scapular and sagittal planes. Results showed that between-day reliability was good for upward scapular rotation (Coefficient of Multiple Correlation; CMC = 0.92) and posterior tilt (CMC = 0.70) but fair for internal rotation (CMC = 0.53) during the arm elevation phase. The waveform error was lower for upward rotation (2.7° to 4.4°) and posterior tilt (1.3° to 2.8°), compared to internal rotation (5.4° to 7.3°). The reliability during the lowering phase was comparable to results observed during the elevation phase. If the protocol outlined in this study is adhered to, the AMC provides a reliable measurement of upward rotation and posterior tilt during the elevation and lowering phases of arm movement.     

The utility of the acromion marker cluster (AMC) in a clinical population

IntroductionThe acromion marker cluster (AMC) is a non-invasive scapular motion tracking method. However, it lacks testing in clinical populations, where unique challenges may present. This investigation resolved the utility of the AMC approach in a compromised clinical population.MethodsThe upper body of breast cancer survivors (BCS) and controls were tracked via motion capture and scapular landmarks palpated and recorded using a digitizer at static neutral to maximum elevation postures. The AMC tracked the scapula during dynamic maximum arm abduction. Both single (SC) and double calibration (DC) methods were applied to calculate scapular angles. The influences of calibration method, elevation, and group on mean and absolute error with two-way fixed ANOVAs with interactions (p < 0.05). Root mean square errors (RMSE) were calculated and compared.ResultsDC improved AMC estimation of palpated scapular orientation over SC, especially at higher arm elevations; RMSE averaged 11° higher for SC than DC at maximum elevation, but the methods were only 2.2° different at 90° elevation. DC of the AMC yielded mean error values of ∼5–10°. These approximate errors reported for AMC with young, lean adults.ConclusionsThe AMC with DC is a non-invasive method with acceptable error for measuring scapular motion of BCS and age-matched controls.     

Tracking the scapula using the scapula locator with and without feedback from pressure-sensors: A comparative study

BackgroundThe scapula locator method has associated intra-observer and inter-observer errors caused by the dependency on the observer to locate the scapular landmarks. The potential effect of the pressures applied by the observer on the measured scapular kinematics when this method is used has also been overlooked so far. The aim of this study was to investigate the effect of using feedback on the pressures applied on the scapula using the locator on the intra-observer and inter-observer reliabilities of the method as well as on the kinematics obtained using this method.MethodsThree observers tracked the scapular motion of the dominant shoulder of each subject using the locator with no reference to pressure-feedback for three trials of bilateral elevation in the scapular plane and using the locator with pressure-feedback for three other trials. Variations between the measurements obtained were used to calculate the intra-observer errors and variations between the measurements obtained by the three observers for the same subject were used to calculate inter-observer errors. Repeated-measures ANOVA tests were used to look at differences between the two methods in terms of intra-observer and inter-observer errors and scapular kinematics.FindingsUsing pressure-feedback reduced the intra-observer errors but had no effect on the inter-observer errors. Different scapular kinematics was measured using the two methods.InterpretationsPressure-feedback improves the reliability of the scapula locator method. Differences in the scapular kinematics suggest that unregulated pressures have an effect on the physiological scapular motion.     

Non-invasive determination of coupled motion of the scapula and humerus--an in-vitro validation

Measuring the motion of the scapula and humerus with sub-millimeter levels of accuracy in six-degrees-of-freedom (6-DOF) is a challenging problem. The current methods to measure shoulder joint motion via the skin do not produce clinically significant levels of accuracy. Thus, the purpose of this study was to validate a non-invasive markerless dual fluoroscopic imaging system (DFIS) model-based tracking technique for measuring dynamic in-vivo shoulder kinematics. Our DFIS tracks the positions of bones based on their projected silhouettes to contours on recorded pairs of fluoroscopic images. For this study, we compared markerlessly tracking the bones of the scapula and humerus to track them with implanted titanium spheres using a radiostereometric analysis (RSA) while manually manipulating a cadaver specimen's arms. Additionally, we report the repeatability of the DFIS to track the scapula and humerus during dynamic shoulder motion. The difference between the markerless model-based tracking technique and the RSA was ±0.3 mm in translation and ±0.5° in rotation. Furthermore, the repeatability of the markerless DFIS model-based tracking technique for the scapula and humerus was ±0.2 mm and ±0.4°, respectively. The model-based tracking technique achieves an accuracy that is similar to an invasive RSA tracking technique and is highly suited for non-invasively studying the in-vivo motion of the shoulder. This technique could be used to investigate the scapular and humeral biomechanics in both healthy individuals and in patients with various pathologies under a variety of dynamic shoulder motions encountered during the activities of daily living.     

Effects of attachment position and shoulder orientation during calibration on the accuracy of the acromial tracker

The acromial tracker is used to measure scapular rotations during dynamic movements. The method has low accuracy in high elevations and is sensitive to its attachment location on the acromion. The aim of this study was to investigate the effect of the attachment position and shoulder orientation during calibration on the tracker accuracy. The tracker was attached to one of three positions: near the anterior edge of the acromion process, just above the acromial angle and the meeting point between the acromion and the scapular spine. The scapula locator was used to track the scapula during bilateral abduction simultaneously. The locator was used to calibrate the tracker at: no abduction, 30°, 60°, 90° and 120° humerothoracic abduction. ANOVA tests compared RMS errors for different attachment positions and calibration angles. The results showed that attaching the device at the meeting point between the acromion and the scapular spine gave the smallest errors and it was best to calibrate the device at 60° for elevations ≤90°, at 120° for elevations >90° and at 90°or 120° for the full range of abduction. The accuracy of the tracker is significantly improved if attached appropriately and calibrated for the range of movement being measured.     

Method for determining the spatial position of the shoulder with ultrasound-based motion analyzer.

Several methods have been developed recently for the analysis of the spatial motion of the scapula and the arm, whereby the spatial position of shoulder bones is determined in static conditions by interrupting motion. The authors have developed a 3D motion analysis method recording scapular motion in progress with appropriate accuracy in the course of arm movements of various degrees. The objective of this study is to explore the applicability of the method developed, as well as to compare it with and verify it by other methods developed earlier. The position and displacements of shoulder bones were determined on 30 shoulders of 15 healthy people. The newly developed measurement method is based on the mechanical basic principle stating that the position and motion of a rigid body -- in this case, the bones (segments) forming the shoulder joint -- can be calculated at any moment from the spatial coordinates of three points of a segment and any changes thereof in the course of motion. Ultrasound-based triplets providing the three points (fundamental points) by a segment as required for measurement were fixed on the sternum (modeling the trunk), the clavicle, the acromion (modeling the scapula), the upper arm, and the lower arm. The position of the sixteen anatomical points involved in the study were determined by an ultrasound-based pointer in the local coordinate system specified by the fundamental points before starting measurements. The ZEBRIS ultrasound-based motion analysis system was used for measuring the spatial coordinates of triplets in the course of continuous motion. The spatial coordinates of the designated anatomical points can be calculated by the method of triangulation. The method was calibrated by a ZEBRIS mapping (3DCAD) software commercially available, and the measurement error rate of the method was determined by statistical calculations. On the basis of calibration and error calculations it could be established that the accuracy and the reproducibility of the method were appropriate, in accordance with the limit values to be found in the literature.     

Identification of scapular kinematics using surface mapping: a validation study

The immediate goal of this study was to develop and validate a noninvasive, computational surface mapping approach for measuring scapular kinematics by using available motion capture technology in an innovative manner. The long-term goal is to facilitate clinical determination of the role of the scapula in children with brachial plexus birth palsy (BPBP). The population for this study consisted of fourteen healthy adults with prominent scapulae. Subject-specific scapular templates were created using the coordinates of five scapular landmarks obtained from palpation with subjects seated and arms relaxed in a neutral position. The scapular landmarks were re-palpated and their locations recorded in the six arm positions of the modified Mallet classification. The six Mallet positions were repeated with approximately 300 markers covering the scapula. The markers formed a surface map covering the tissue over the scapula. The scapular template created in the neutral position was iteratively fit to the surface map of each trial, providing an estimate of the orientation of the scapula. These estimates of scapular orientation were compared to the known scapular orientation determined from the scapular landmarks palpated in each Mallet position. The magnitude of the largest mean difference about an anatomical axis between the two measures of scapular orientation was 3.8° with an RMS error of 5.9°. This technique is practical for populations with visibly prominent scapulae (e.g., BPBP patients), for which it is a viable alternative to existing clinical methods with comparable accuracy.     

A new method for motion capture of the scapula using an optoelectronic tracking device: a feasibility study

Optoelectronic tracking systems are rarely used in 3D studies examining shoulder movements including the scapula. Among the reasons is the important slippage of skin markers with respect to scapula. Methods using electromagnetic tracking devices are validated and frequently applied. Thus, the aim of this study was to develop a new method for in vivo optoelectronic scapular capture dealing with the accepted accuracy issues of validated methods.

Eleven arm positions in three anatomical planes were examined using five subjects in static mode. The method was based on local optimisation, and recalculation procedures were made using a set of five scapular surface markers.

The scapular rotations derived from the recalculation-based method yielded RMS errors comparable with the frequently used electromagnetic scapular methods (RMS up to 12.6° for 150° arm elevation). The results indicate that the present method can be used under careful considerations for 3D kinematical studies examining different shoulder movements.     

Skin-fixed scapula trackers: a comparison of two dynamic methods across a range of calibration positions

The aim of this study was to establish the optimal methodology for skin-fixed measurement of the scapula during dynamic movement. This was achieved by comparing an optimally positioned Scapula Tracker device (ST) to a previously described palpation device, taken as the true measure of scapular kinematics. These measurements were compared across a range of calibration positions, including the use of multiple calibration positions for a single movement, in order to establish an optimal calibration approach. Ten subjects' scapular motion was measured using this ST and a previously described Acromial Method (AM). The two datasets were compared at a standard, an optimal and a 'multiple' calibration position, thus allowing a direct comparison between two common skin-fixed methods to track the bony kinematics of the scapula across different calibration positions. A comparison was also made with a bone-fixed technique from the literature. At both the standard and optimal calibration positions the ST was shown to be the more accurate measure of internal rotation and posterior tilt, particularly above 100° of humerothoracic elevation. The ST errors were found to be acceptable in relation to clinically important levels. Calibration positions have been shown to have a significant effect on the errors of both skin-fixed measurement techniques and therefore the importance of correct calibration is highlighted. It has thus been shown that a ST can be used to accurately quantify scapular motion when appropriately calibrated for the range of motion being measured.     

Difference between palpation and optoelectronics recording of scapular motion

The aim of this study is to determine the errors of scapular localisation due to skin relative to bone motion with an optoelectronic tracking system. We compared three-dimensional (3D) scapular positions obtained with skin markers to those obtained through palpation of three scapular anatomical landmarks. The scapular kinematics of nine subjects were collected. Static positions of the scapula were recorded with the right arm elevated at 0°, 40°, 80°, 120° and 160° in the sagittal plane. Palpation and subsequent digitisation of anatomical landmarks on scapula and thorax were done at the same positions. Scapular 3D orientation was also computed during 10 repeated movements of arm elevation between 0° and 180°. Significant differences in scapular kinematics were seen between static positions and palpation when considering anterior/posterior tilt and upward/downward rotation at angles over 120° of humeral elevation and only at 120° for internal/external rotation. There was no significant difference between positions computed during static positions and during the movement for the three scapular orientations. A rotation correction model is presented in order to reduce the errors between static position and palpation measurement.     

Redescription of Rayososaurus agrioensis Bonaparte (Sauropoda, Diplodocoidea), a rebbachisaurid from the early Late Cretaceous of Neuquén

The material belonging to the holotype of Rayososaurus agrioensis Bonaparte is redescribed. The great development of the acromion process, directed in a markedly posterior direction, and the ventral margin of the scapula with a strong ventrodistal expansion, interpreted as autapomorphies of the taxon, justify the validity of the species. Although the material is rather fragmentary, the racquet-shaped scapula, the distal expansion positioned at the same height as the proximal expansion, and the well-developed acromion process allow the taxon to be included within Rebbachisauridae. At the same time, the angle of less than 90? between the coracoid articulation and the scapular blade, together with the great development of the acromion process of the scapula, justify its inclusion in a clade situated as a sister group of Cathartesaura. On the basis of the stratigraphic calibration of the phylogenetic analysis, an important diversification event of the rebbachisaurids is deduced during the Hauterivian-Barremian. In this context, the presence of two monophyletic groups, one of which comprises African-European taxa and the other South American taxa, would place the definitive separation of South America and Africa within this time interval.     

Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: Evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture

Background

The current method of treatment for persistent internal rotation due to the medial rotation contracture in patients with obstetric brachial plexus injury is humeral derotational osteotomy. While this procedure places the arm in a more functional position, it does not attend to the abnormal glenohumeral joint. Poor positioning of the humeral head secondary to elevation and rotation of the scapula and elongated acromion impingement causes functional limitations which are not addressed by derotation of the humerus. Progressive dislocation, caused by the abnormal positioning and shape of the scapula and clavicle, needs to be treated more directly.

Methods

Four patients with Scapular Hypoplasia, Elevation And Rotation (SHEAR) deformity who had undergone unsuccessful humeral osteotomies to treat internal rotation underwent acromion and clavicular osteotomy, ostectomy of the superomedial border of the scapula and posterior capsulorrhaphy in order to relieve the torsion developed in the acromio-clavicular triangle by persistent asymmetric muscle action and medial rotation contracture.

Results

Clinical examination shows significant improvement in the functional movement possible for these four children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy.

Conclusion

These results reveal the importance of recognizing the presence of scapular hypoplasia, elevation and rotation deformity before deciding on a treatment plan. The Triangle Tilt procedure aims to relieve the forces acting on the shoulder joint and improve the situation of the humeral head in the glenoid. Improvement in glenohumeral positioning should allow for better functional movements of the shoulder, which was seen in all four patients. These dramatic improvements were only possible once the glenohumeral deformity was directly addressed surgically.     

Validation of a mathematical approach to estimate dynamic scapular orientation

The goal of this study was to develop and validate a non-invasive approach to estimate scapular kinematics in individual patients. We hypothesized that individualized mathematical algorithms can be developed using motion capture data to accurately estimate dynamic scapula orientation based on measured humeral orientations and acromion process positions. The accuracy of the mathematical algorithms was evaluated against a gold standard of biplane fluoroscopy using a 2D to 3D fluoroscopy/model matching process. Individualized linear models were developed for nine healthy adult shoulders. These models were used to predict scapulothoracic kinematics, and the predicted kinematics were compared to kinematics obtained using biplane fluoroscopy to determine the accuracy of the algorithms. Results showed strong correlations between mathematically predicted kinematics and validation kinematics. Estimated kinematics were within 8° of validation kinematics. We concluded that individualized linear models show promise for providing accurate, non-invasive measurements of scapulothoracic kinematics in a clinical environment.     

The bipedicled osteocutaneous scapula flap: a new subscapular system free flap

Thirty-six adult dissections (14 cadaver and 22 operative) demonstrate the constant presence of the angular branch of the thoracodorsal artery as a vascular pedicle to the inferior pole of the scapula. This vessel originated in all cases just proximal or distal to the serratus branch of the thoracodorsal artery and arborized to the periosteum 6 to 9 cm from the bony branch of the circumflex scapular artery. In eight patients, scapular osteocutaneous flaps were raised preserving the angular branch and the circumflex scapular artery and dissecting up to the subscapular vessels. In all cases, bone was independently perfused by the angular branch. In all six cases where the angular branch was the sole supply to bone, technetium-99m scans demonstrated perfusion. Addition of this vascular pedicle to scapula bone allows two separate bone flaps with one microanastomosis and provides a longer arc of rotation between skin supplied by the circumflex scapular artery and bone. Donor-site morbidity was no greater than with the standard scapula flap.     

A comparison of two non-invasive methods for measuring scapular orientation in functional positions

Identification of scapular dyskinesis and evaluation of interventions depend on the ability to properly measure scapulothoracic (ST) motion. The most widely used measurement approach is the acromion marker cluster (AMC), which can yield large errors in extreme humeral elevation and can be inaccurate in children and patient populations. Recently, an individualized regression approach has been proposed as an alternative to the AMC. This technique utilizes the relationship between ST orientation, humerothoracic orientation and acromion process position derived from calibration positions to predict dynamic ST orientations from humerothoracic and acromion process measures during motion. These individualized regressions demonstrated promising results for healthy adults; however, this method had not yet been compared to the more conventional AMC. This study compared ST orientation estimates by the AMC and regression approaches to static ST angles determined by surface markers placed on palpated landmarks in typically developing adolescents performing functional tasks. Both approaches produced errors within the range reported in the literature for skin-based scapular measurement techniques. The performance of the regression approach suffered when applied to positions outside of the range of motion in the set of calibration positions. The AMC significantly underestimated ST internal rotation across all positions and overestimated posterior tilt in some positions. Overall, root mean square errors for the regression approach were smaller than the AMC for every position across all axes of ST motion. Accordingly, we recommend the regression approach as a suitable technique for measuring ST kinematics in functional motion.     

Scapular taping alters kinematics in asymptomatic subjects

BackgroundScapular taping is frequently used in the management of shoulder pain and as a part of injury prevention strategies in sports. It is believed to alter scapular kinematics and restore normal motion. However, there is little evidence to support its use. The aim of the study was to investigate the effect of shoulder taping on the scapular kinematics of asymptomatic subjects.MethodThirteen asymptomatic subjects performed elevations in the sagittal and scapular planes with no tape and after the application of tape. A motion tracking system and a scapula locator method were used to measure the shoulder movement. Co-ordinate frames were defined for the thorax, humerus and scapula and Euler angles were used to calculate joints rotations.ResultsScapular taping increased the scapular external and upward rotations and posterior tilt in elevations in the sagittal plane (p < 0.001). In the scapular plane, taping increased scapular external rotation (p < 0.05).ConclusionsTaping affects scapulothoracic kinematics in asymptomatic subjects. The effect may be different for different planes of movement. The findings have implications on the use of taping as a preventive measure in high-risk groups. Further work is needed to assess the effect of taping on symptomatic populations.